What is the treatment regimen for vaginal atrophy using vaginal estrogen and progesterone?

Vaginal Estrogen and Progesterone Treatment for Vaginal Atrophy

Low-dose vaginal estrogen therapy is the most effective treatment for vaginal atrophy when non-hormonal options fail, with progestogen generally not indicated when using low-dose local estrogen for women without a uterus. 1, 2

First-Line Treatment: Non-Hormonal Options

• Regular use of vaginal moisturizers provides daily maintenance of vaginal tissue health and relieves dryness and discomfort 1, 2
• Water-based lubricants are recommended during sexual activity to reduce friction and discomfort 1, 2
• Silicone-based lubricants may be more effective as they last longer than water-based products 1, 2
• Topical vitamin D or E can provide additional symptom relief for vaginal dryness 2

Second-Line Treatment: Physical Therapies

• Pelvic floor physical therapy can significantly improve sexual pain, arousal, lubrication, and overall satisfaction 1, 2
• Vaginal dilators benefit women experiencing pain during sexual activity and those with vaginal stenosis 1, 2

Third-Line Treatment: Hormonal Options

Vaginal Estrogen Formulations

• Available in several forms: creams, tablets, and rings (sustained-release) 1
• Low-dose formulations minimize systemic absorption while effectively treating symptoms 1, 2
• All low-dose vaginal estrogen products are equally effective at recommended doses 3
• Typical dosage for estradiol vaginal cream is 10 to 20 mg every four weeks 4

Progestogen Considerations

• For women with an intact uterus, progestin should be added to reduce the risk of endometrial cancer 4
• Progestogen is generally not indicated when low-dose estrogen is administered locally for vaginal atrophy in women without a uterus 4, 3

Treatment Duration and Monitoring

• Treatment should be continued as long as distressful symptoms remain 3
• Patients should be reevaluated periodically (every 3-6 months) to determine if treatment is still necessary 4
• For women with an intact uterus, appropriate diagnostic measures should be taken to rule out malignancy in cases of persistent or recurring abnormal vaginal bleeding 4

Special Considerations

Cancer Patients

• For breast cancer survivors, non-hormonal options should be tried first 1, 2
• Women on aromatase inhibitors should generally avoid vaginal estrogen as it may increase circulating estradiol 1
• Estriol-containing preparations may be preferable for women with hormone-sensitive cancers as estriol is a weaker estrogen that cannot be converted to estradiol 1

Alternative Hormonal Options

• DHEA (prasterone) is FDA-approved for vaginal dryness and pain with sexual activity 1, 2
• Ospemifene (a selective estrogen receptor modulator) effectively treats vaginal dryness in postmenopausal women without a history of estrogen-dependent cancers 2

Treatment Persistence and Adherence

• Vaginal tablets show better treatment persistence compared to cream formulations (mean treatment duration: 103.4 days for tablets versus 44.6-48.1 days for creams) 5
• Incomplete treatment may lead to worsening symptoms and reduced quality of life 2
• Unlike vasomotor symptoms which tend to resolve over time, atrophic vaginitis symptoms may persist indefinitely and often worsen without treatment 1

Contraindications

• History of hormone-dependent cancers 6, 1
• Abnormal vaginal bleeding that has not been diagnosed 6
• Active or recent history of pregnancy 6
• Active liver disease 6